Therapeutic use exemption in exercise-induced asthma

DOCTOR’S CORNER with Dr JOSEPH KABUNGO
EXERCISE Induced Asthma (EIA) is one condition which has to be managed in order to allow a person to participate fully in sport.A therapeutic use exemption (TUE) can be the answer to manage this condition and avoid positive dope tests.
During one discussion with a sports journalist, I had to stress the importance of applying for a TUE at least 21 days before engaging in competition where doping controls are done.
Exercise induced asthma has to be given special consideration in this case.
Being young and in perfect health is the desire of many young sports men.
This is not different from our young sports men and women in Zambia. As the level of participation increases so does the need to adequately identify and treat conditions, which might hinder a young sports man from fully participating in sport.
This has got its own challenges in identifying those at risk, because of the limited number of medical personnel actively involved in taking care ofÂ sports men.
It is not only the medical condition, which we have to deal with, but also the treatment options available.
Asthma is one of the chronic respiratory conditions affecting millions of people across the world. Sports men and women have not been spared and the challenge arises because of the treatment options available.
In sports men and women it is always important that asthma is well understood so that athletes are empowered with knowledge on how to cope with this condition.
Asthma is a life threatening condition if not managed.
The discussion on asthma will be broken down into a brief discussion on the general picture of asthma in the general population and then I will narrow down to asthma which is exercise induced.
Exercise Induced Asthma (EIA) will be of importance to understand by various coaches. It must be understood that asthma is a chronic respiratory condition affecting the air passages.
From basic biology, it was seen that the respiratory system has got different parts starting from the nostrils when air enters all the way to the alveoli or the air sacs, which are functional units of the lungs.
Remember when we breathe in and out, the air has to move through the air passages just like the way air passes through a connecting tube when pumping a tyre or a ball.
But for the air which goes in a tyre or a ball remains there assuming there is no leak but for the human air passages, the air has to go in and out.
This happens when we breathe in and out or inspire and expire.
Asthma has to deal with the narrowing of the air passages known as bronchioles.
We know that when we breathe in, the lungs expand and are filled up with air and once the gas exchange has occurred the air has to go out.
In asthma their is narrowing of these air passages through which air has to come out hence the various symptoms which are seen in asthmatic patients.
The narrowing of the air passages can be due to causes ranging from inflammatory causes due to the release of certain chemicals from cells lining the respiratory tract.
Some of the known causes and triggers of asthma include exposure to certain environmental particles like pollen and other droppings from domestic pets, atmospheric pollution (sulphur dioxide), certain drugs, viral infections of the upper respiratory tract, cold air, emotions, irritant dusts, vapours and fumes (perfumes, cigarette smoke) and genetic factors (family predisposition or history of asthma).
The relationship between exercise and asthma has been known for centuries.
In his land mark a treatise of the asthma, Sir John Floyer wrote in 1717 that â€˜All Violent Exercise makes the Asthmatic To Breath Shortâ€™ Exercise Induced Asthma is defined as the acute transient airway narrowing that occurs during but more often and more distinctively after exercise or more distinctly referred to as fall in forced expiratory volume in one second of > than 10 percent.
You can tell from the definition that the volume of air that is forcefully expired in one second is reduced and this is an important factor which physicians use when defining EIA.
In up to 90 percent of people with known asthma, exercise is a trigger. In some, EIA may be the only manifestation of asthma.
The prevalence of asthma in the general population varies from 5-20 percent while in athletes it can be as high as 10-70 percent.
There are a lot of ways through which the narrowing of the air passages occur.
Some of the ways are through inflammatory processes in the air passages.
There is controversy surrounding the exact mechanism with some suggesting that the loss of water by evaporation from the airways causing cooling and /or dehydration of the air way surface.
This through a lot of mechanisms cause release of bronchial-active substances from cells called mast cells and also other cells from surrounding areas causing narrowing of the air passages.
One of the mediators released by the mast cells is histamine.
The histamine is a potent bronchoconstrictor i.e. it causes airway narrowing.
The other mechanisms involve the nerve supply to the respiratory tract and also the reduction in the production of prostaglandins which help in dilating the air passages or keeping them wide open.
The other term which we have to be familiar with is atopy.Atopy is the term mainly used to describe individuals or athletes who develop antibodies of the IgE type as a result of being exposed to certain materials in the environment. The IgE antibodies are present in 30-40% of the population and there is a strong link between serum IgE and prevalence of asthma and airway responsiveness to histamines.EIA is more severe in those individuals who are atopic.
The common signs and symptoms of asthma and EIA are mainly due to the narrowing of the air passages.
Symptoms include shortness of breath, wheezing, chest pain with coughing, and chest tightness.
Typically the symptoms occur within five to ten minutes after starting vigorous exercises, but maximal airway narrowing occurs only after cessation of the exercise.
As it can be seen from the clinical picture of an asthmatic patient, it becomes important that a diagnosis of asthma is promptly made so that treatment is not delayed.
Asthma in its different forms can either be mild, moderate or severe.
A severe asthmatic attack which is not promptly treated can be very debilitating and often fatal.
In this era especially with the advances made in the treatment of asthma and diagnostic facilities, fatalities as a result of asthma should be a rare occurrence.
Exercise induced asthma becomes important in players or athletes, who compete at a very high level.
It is for this one reason the management of asthma in football players and other athletes performing at a very high level has to be taken seriously. Firstly, player education is important so that they understand the type of condition that they have.
A player with Exercise Induced Asthma will not perform at the expected level because of the difficulties in breathing which they have as a result of the narrowed air passages.
EIA significantly reduces performance. It is not unusual to find 45 minutes players.
This is not for technical reasons, but on the assumption that they cannot last 90 minutes.
It is for this reason that such players will benefit from a thorough medical assessment.
The other thing to remember is that exercise induced asthma can be managed and prevented.
For questions and comments write to Dr Kabungo Joseph
Email: zengajk@yahoo.com or kateulejk@gmail.com